Mental health consultation

[+] yes, present, positive [-] no, absent, negative [~] equivocal [\] not applicable, not performed [?] unknown, unsure, unavailable { } annotation, comment PRESENTING COMPLAINTS OR ISSUES Reasons for visit: - mental health consultation Presenting symptoms: [-] low/depressed mood [-] anxiety [-] mood swings [-] reduced ability to cope with daily problems or stress [-] irritability [-] lowered energy or motivation [-] elevated energy/arousal [-] fears, worries, or feelings of guilt [-] changes in eating habits or appetite [-] weight loss/gain [-] libido changes [-] confused thinking or reduced ability to concentrate [-] detachment from reality (delusions), paranoia or hallucinations [-] trouble understanding and relating to situations and to people Details: - Sleep: [-] usual bedtime: [-] hours of sleep: [-] initial insomnia [-] early morning wakening [-] daytime sleepiness Recent stressors/triggers: [-] financial [-] housing [-] employment (workloads, conflict, performance management, job loss) [-] physical health concerns [-] legal (including crime or victim of crime) [-] relationships (including partner, family, friends, social media) [-] isolation/loneliness [-] loss/grief [-] psychological trauma [-] emptiness/lack of a sense of meaning or purpose Details: - Suicide/self-harm: [-] ideation/thoughts [-] intent/plan Harm to others: [-] ideation/thoughts [-] intent/plan PAST MEDICAL HISTORY Past mental health history: [-] anxiety [-] depression [-] substance abuse (alcohol/other drugs) [-] psychological/psychiatric treatment Mental health treatment history: - Medical/biological history: [-] acquired brain injury [-] dementia [-] neurological conditions [-] menstrual dysphoria [-] endocrine conditions [-] medication affecting mood Childhood development: [-] delayed early childhood milestones [-] learning difficulty [-] adverse childhood experiences (ace): [-] abuse: [-] emotional abuse [-] physical abuse [-] sexual abuse [-] neglect: [-] emotional neglect [-] physical neglect [-] household challenges: [-] mother treated violently [-] substance abuse [-] mental illness [-] parental separation/divorce [-] crime/incarceration SOCIAL HISTORY Accommodation: [-] lives alone [-] lives with partner [-] lives with family [-] lives in share accommodation [-] lives in hostel [-] no permanent home Smoking: [-] never smoked [-] current smoker [-] ex-smoker If smoker, pack-year history: Alcohol intake: [-] nil [-] alcohol use If yes, standard drinks per week: Exercise: [-] regular exercise If yes: Type: Frequency: Occupational history: Current employment: Occupation: Employer: Date started: Previous employment (if relevant): Occupation: Years: Occupation: Years: Educational history: Highest level of education: Discipline/s: Social contact: (hours per week) Face-to-face: Telephone/video calls: Sport/physical/recreational activities: Social media use: Other screen time: Services and care received: - Patient or carer's social concerns: - FAMILY HISTORY Relevant family history: [-] Anxiety [-] Depression [-] Substance use disorder [-] Schizophrenia [-] Suicide MENTAL STATE OBSERVATIONS {abnormalities} [-] appearance [-] behaviour [-] motor activity [-] speech [-] mood (patient [-] subjective) [-] affect (examiner [-] observations) [-] thought processes [-] thought content [-] perceptions [-] cognition [-] orientation [-] attention/concentration [-] memory [-] abstract reasoning [-] insight [-] judgement [-] numeric skills [-] construction and spatial skills [-] abstract thinking Mental health assessment tool (e.g. DASS 21, K10, PHQ-9): ASSESSMENT Main symptom areas: [-] neurological and psychological development [-] cognition [-] attention/hyperactivity [-] thought/psychosis [-] low/depressed mood [-] anxiety [-] bipolar features [-] fear/phobia [-] obsession/compulsion [-] stress/trauma [-] feeding/eating [-] personality/behaviour [-] substance use [-] bodily distress/somatisation [-] sexual function [-] gender Diagnosis/es (if relevant): - Predisposing risk factors: - Protective factors: - Impairment: Social: Employment: Education: Other potential risk factors: [-] culturally or linguistically diverse [-] disadvantaged geographical area or residence [-] financial disadvantage [-] prenatal and postnatal depression [-] ageing/cognitive decline [-] severe/high mental health needs MANAGEMENT PLAN Treatment goals: - Prescribed medication: - Patient education/home care advice: [+] Exercise: At least 20-30 minutes of physical activity (such as walking) daily. [+] Social activity goals: (hours per week) Face-to-face: Social media limits: Psycho education/internet referrals or recommendations: [-] Headtohealth.gov.au Comprehensive list of australian resources. [-] Ontrack.org.au Free access to online programs, information, quizzes and advice. [-] Mycompass.org.au Personalised self-help tool for your mental health. [-] Thiswayup.org.au Practical tools to take care of your mental health. [-] Mindspot.org.au Free, anonymous assessment and treatment for australian adults experiencing stress, anxiety, depression, ocd, ptsd, and chronic pain. [-] Ecouch.com.au Interactive self-help and evidence-based information for social anxiety. [-] Moodgym.com.au Interactive self-help book which helps you to learn and practise skills that can help prevent and manage symptoms of depression and anxiety. [-] Reasonstostay.com.au Suicide prevention skills. Support services and crisis services: - Suicide call back service (anyone thinking about suicide) Www.suicidecallbackservice.org.au 1300 659 467 - Lifeline (anyone having a personal crisis) Www.lifeline.org.au 13 11 14 - Beyond blue support service (anyone feeling anxious or depressed) Www.beyondblue.org.au 1300 22 4636 - Kids help line (counselling for young people aged 5 to 25) Www.kidshelpline.com.au 1800 55 1800 - Mensline australia (men with emotional and relationship concerns) Www.mensline.org.au 1300 78 99 78 - Open arms (veterans and families counselling) Www.openarms.gov.au 1800 011 046 Referrals: - FOLLOW-UP Outstanding issues: - Next appointment: - [dqref.com 260113]

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Related items

• DASS 21
• K10 (Kessler psychological distress scale)
• Mental health progress consultation
• Mini-mental state examination (MMSE)
• Nervous system
• Personality assessment questionnaire (PAQ)
• PHQ-9 depression questionnaire
• Psychotropic medication monitoring

MBS (Australia) item numbers

* Indicates telehealth services.

^ Indicates phone services.

• GP mental health treatment plans
  • Plan preparation
    • GPs who HAVE completed Mental Health Skills Training
      • Item 2715: 20-39 minutes
      • Item 92116: 20-39 minutes*
      • Item 2717: 40[+] minutes
      • Item 92117: 40[+] minutes*
    • GPs who have NOT completed Mental Health Skills Training
      • Item 2700: 20-39 minutes
      • Item 92112: 20-39 minutes*
      • Item 2701: 40[+] minutes
      • Item 92113: 40[+] minutes*

External links

• ICD-11 Mental, behavioural or neurodevelopmental disorders